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Accessible to all
Removing barriers to good oral health

Are you confident Introduction number of people with Alzheimer’s disease

Special Care Dentistry is concerned with: and dementia will increase as the population
in your approach to ‘The improvement of oral health of individu- ages. One in four adults experience mental
als and groups in society who have a physical, distress or a mental health problem. Of the
every patient who sensory, intellectual, mental, medical, emo- 1.2 million people with a learning disabil-
enters the surgery? tional or social impairment or disability or, ity, 20% are severely or profoundly impaired.
more often, a combination of these factors’. More than 300,000 children have a disabil-
Let Associate Specialist This is the technical definition which includes ity; the number of children and adolescents
visible and hidden disabilities. diagnosed with cancer is increasing annu-
Janet Griffiths introduce Special care includes people with a physical ally, and 10% of children aged five to 15 have
you to Special disability, learning disability, autistic spectrum behavioural problems causing mental or
disorders, mental health problems, vision and emotional distress.
Care Dentistry. hearing impairment, communication dif- Impairment and disability are common,
ficulties, Alzheimer’s disease and dementia, affecting a large section of the population and
and a wide range of complex medical and all age groups. However, most people requir-
emotional conditions that limit activities of ing Special Care Dentistry are in older age
daily life and present challenges in access- groups. While the oral health of the popula-
ing and delivering oral health care. The list is tion has improved over the last three decades,
not exhaustive. In general terms, ‘special care’ disadvantaged and disabled groups continue
covers groups listed under the Disability Dis- to have poorer levels of oral health, and expe-
crimination Act (DDA, 1995). rience barriers to maintaining oral health and
accessing dental services. Special Care Den-
Why do we need Special tistry aims to address these inequalities in a
Care Dentistry? growing disabled population.
The DDA applies to people whose disability
has a substantial effect on the way the individ- Addressing the needs
ual can carry out normal day to day activities. Special Care Dentistry has received consid-
Estimates suggest that around 10 million erable publicity since the General Dental
adults are covered by the DDA and this will Council announced the new specialty in Spe-
increase as the Act now includes people with cial Care to address the needs of people with
HIV, cancer and multiple sclerosis. more severe disability and complex additional
There is no single standard measure of disa- needs. Many disabled people, despite social
bility. The last UK census reported 9.5 million and environmental limitations, lead full and
disabled adults; long term illness limits the active lives and want equal treatment to those
lifestyle of more than a third of people aged without disability in primary care.
65 to 74 and almost half of people aged over The DDA aims to end discrimination
75. Loss of mobility increases with age; the against disabled people by removing barriers
greatest decline is in people aged 75 and over. to their full participation in society. How-
Sensory impairment is more common with ever, it also recognises that disabled people
advancing age; visual impairment affects are discriminated against as much by barri-
around 80% of people over 60, and 22% have ers created by an unthinking society as by the
both visual and hearing impairment. The attitudes of individuals.

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Since 1999, service providers have been care patients are referred to secondary care; be consulted; local Access Groups are a source
required to make reasonable changes to poli- what they largely want is dental care, in a dis- of informed advice.
cies, procedures and practices, or provide the ability friendly practice, from a sympathetic
service by a reasonable alternative means, for dental team that understands their specific Ability
example providing a domiciliary visit. From needs. Lack of confidence, training or exper- This embraces the individual’s physical
October 2004, the Act required ‘reasonable tise in treating disabled people may be factors and cognitive ability for self-care with oral
steps’ to reduce physical barriers that affect in the decision to refer. Concerns about the hygiene, and in seeking and accessing serv-
access. This has presented the biggest chal- quality of care that can be provided, inade- ices, and carers’ ability to provide the required
lenge to service providers but the key to quate remuneration for extra clinical time, support. Oral hygiene is an integral part of
compliance is ‘reasonableness’. need for special facilities, and lack of under- personal care. Techniques for maintaining
The DDA has put the issue of disability dis- standing and experience in dealing with oral health may be difficult to learn; for others
crimination firmly into the public arena and ‘different’ behaviour create barriers to treat- assistance and supervision are essential. Oral
created pressure to address barriers to oral ment in primary care. health education and practical training in oral
health care. This is a broad picture of some hygiene should be mandatory for all profes-
issues that influenced the need to develop the Access sional carers; regrettably this is not the case.
speciality in combination with Government Access to information, transport and serv- Impaired manual control and dexterity
reports and frameworks for improving the ices are common barriers to oral health. influence standards of oral hygiene. People
health of the nation, and the demands and Impaired mobility leads to social isolation with severe or profound impairment are
growing confidence of disabled people and which is itself a barrier to obtaining informa- dependent on the knowledge and skill of
their families for equitable services, a demand tion, and conditions people over time to have carers for all aspects of oral health care. Aids
now backed by legislation. low expectations of services. Information on and adaptations to assist patients and carers
oral hygiene, preventive care and treatment, with oral hygiene may be required.
Barriers to oral health the accessibility of dental services, NHS treat- The dental team’s ability to provide
Every patient is an individual with individ- ment and domiciliary care are important appropriate care and deliver equitable
ual approaches to managing their disability barriers to be addressed. services must be considered. Training in dis-
therefore a holistic approach to planning care ‘Reasonable changes’ to improve physi- ability confidence, an approach that focuses
is essential. An ‘ABC’ approach identifies cal access to dental premises should have on a best practice approach to manag-
many universal inter-related barriers to oral been addressed by 2004. Where possible, ing disability issues positively in a dental
health (Griffiths and Boyle, 2005). Attitudes, premises should permit unassisted access for environment, will help address some of the
access and ability, barriers and communica- wheelchair users and people with walking professional barriers.
tion can be viewed from the perspective of the aids. Entry phones may be a barrier for deaf
patient, carers (family or professional) and the people. Internal movement should be unre- Barriers to oral health
dental team. stricted, free of obstacles, with an accessible Barriers are related to the nature, onset and
toilet. Doors with opening devices accom- severity of the condition, symptom man-
Attitudes modate people with a range of disabilities. agement and treatment. Dietary changes to
Attitudes underpin health behaviour: atti- Waiting areas should include seating of differ- manage feeding difficulties and swallow-
tudes to oral health and disease; the need ent heights and a reception desk accessible to ing disorders and improve nutritional status
for oral health care and dental attendance; wheelchair users. Signs and notices which are increase the risk of dental caries because of
dietary intake; preventive regimes; and the adequately lit and in a suitable sized font help increased oral retention of puréed foods and
relative value placed on these in the context of to meet the needs of the visually impaired. thickened fluids. High calorie food supple-
the individual’s ability to cope with life, and A model surgery would have a hoist, ments are frequently prescribed to maintain
the pressures of caring. Oral health may have space to treat a patient in their wheelchair, nutritional status; this is a particular prob-
a low priority in the daily context of coping and appropriate transfer aids such as slid- lem in older people with poor appetites who
with impairment and disability, and the addi- ing boards and turn-table. However, many are encouraged to sip small amounts fre-
tional cost of living with disability. simple adaptations and changes in practice quently throughout the day. Since a greater
The DDA recognises that discriminatory can be achieved with little expense. Disabled proportion of older people are retaining
attitudes exist in health services. Many special people are themselves the experts and should teeth into later life, this presents challenges to

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maintaining complex restorations affected by consequences of having or not having treat- care must be considered as an alternative for
recurrent caries. ment, and the ability to use and communicate people who encounter problems with physi-
Oral side effects of medication are a risk that information in decision making. cal access or are housebound.
factor for oral health. Although these are rel- Communication impairment does not
atively uncommon, many patients requiring indicate lack of capacity. Consultation and Training the team
special care are taking a cocktail of medica- collaboration with significant persons, family, ‘Disability confidence’ can be developed in
tion. The commonest side effect is dry mouth carers, advocates and health professionals may the dental team through training in:
with increased risk of caries, periodontal dis- be required to establish this. If the patient does • disability discrimination and the
ease, oral infections and denture problems. not have the capacity for informed consent, relevant legislation
Dry mouth (xerostomia) is associated with the responsible clinician will consult signifi- • disability confident language and etiquette
a wide range of medication, and the cause cant persons to get agreement for a treatment • an understanding of the medical and
of significant oral discomfort. Appropriate plan that is in the patient’s best interests, and social models of disability
advice to relieve discomfort and aggressive record the outcome of discussion. • an understanding of the impact of
preventive programmes are essential. As new The dental team should be familiar with different types of impairment.
drugs are developed and side effects are techniques to facilitate communication. Face
reported, it is essential to check the current to face conversations, clear speech, jargon free This provides a foundation for reducing dis-
British National Formulary. language, short sentences, and closed ques- criminatory barriers in dental practice.
tions allowing adequate time for a response The British Society for Disability and Oral
facilitate communication. Pen and paper, Health (BSDH) has been pivotal in promot-
‘The dental the written word, good lighting for lip read-
ing, gestures and facial expression are helpful
ing developments in Special Care Dentistry.
Membership gives reduced fees at meet-

team should be for people who are deaf or hearing impaired;

texting, email and text-phones are effective
ings, subscription to the Journal of Disability
and Oral Health, and a support network for
for arranging appointments. Signs, gestures the dental team. Increased awareness has
familiar with and communication charts are helpful for led to the development of a range of useful
speech loss after stroke or brain injury. Pic- resources. BSDH will shortly publish guid-
communication tures and images are most effective for people
with learning difficulties. Organisations such
ance for PCTs and LHBs for commissioning
special care dental services in primary care. It

techniques.’ as SIGNALONG, the Stroke Association and

the National Autistic Society provide helpful
now requires the commitment of the dental
team to take advantage of the opportunity
advice on communication techniques. to redress these inequalities in oral health,
It is beyond the scope of this article to sum- and make Special Care Dentistry accessible
marise the commonest conditions in Special Special Care Dentistry: accessible to everyone.
Care Dentistry and the impact of long-term to all
medication on oral health. However an assess- An essential component of Special Care Den- Dental team resources
ment of diet and medication are important in tistry is about reducing barriers so that good 1. Special Care Dentistry. An interactive learning
assessing risk factors which present barriers oral health is accessible to all. Disabled people programme for the dental team. Department of
Health, 2006.
to oral health. want high quality mainstream dental services,
2. Griffiths J, Boyle S. Holistic Oral Care: a practical
in a universally acceptable environment that approach. UK: Stephen Hancocks Ltd, 2005.
Communication does not discriminate, is safely accessible to 3. Making sense of the mouth. (CD, video and illustrated
Successful communication — central to all all, and with the support and advice of expert booklet.) UK: Glasgow Dental School, 2001.
aspects of health care — is based on com- and specialist services when required. There 4. British Society for Disability and Oral Health.
www.bsdh.org.uk.
prehension, and an essential component of may be limitations to what can be achieved
5. British National Formulary. www.bnf.org.
obtaining informed consent. It is the clini- in changing the physical environment but
cian’s duty to assess capacity, which is based a simple audit of the environment, current Thanks to HANDS for the use of the image
on ability to understand and retain informa- practices and procedures will undoubtedly top left, this page, and to Cardiff & Vale NHS
tion relative to treatment, especially as to the identify areas for improvement. Domiciliary Trust for the image top centre, this page.

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